Neurological Focused Exams

10 May 2012 / Impairment Physical Exam / 0 Comment

Neurological Focused Exams should include documentation of cranial nerves 2-12, and vision screening corrected with lenses or pin hole if appropriate.

Comment on:

• facial symmetry,
• light and sharp touch,
• cold and warm perception,
• motor grade testing (0-5 Grade Testing, page 484, Table 16-11, Chapter 16 Upper Extremity, AMA Guides 5th Edition, AMA Press, 2004),
• deep tendon reflexes, long tract findings (clonus and plantar reflexes),
• in addition to coordination (finger to nose, heel to shin motions), and
• testing for ataxia (tandem gait testing and Romberg testing).

The Neurological Sensory Exam

01 May 2012 / Impairment Physical Exam / 0 Comment

Light touch sensory documentation is adequate if there are no sensory complaints, however, if “numbness” or “tingling” is noted in the history, it is advised to objectively document sensory complaint levels by using the Seims-Weinstein monofilament sets.

 

I begin with the lightest weight in my set which is 0.07gm. Be certain the employee understands what the testing is looking for and how a positive sensation is registered.

 

I do this by showing the employee the set, letting them apply the monofilament themselves (which has been mis understood as a needle by many an employee) and confirming they can relay a positive pre-examination test before closing their eyes and having the testing performed, right vs. left sides.

 

A Seims-Weinstein filament weight is exercised properly when the filament is applied perpendicular and the body of the filament is bent. Do not drag or tickle the filament across the skin area being tested. Also, on hands and feet where there may be callus, apply the filament testing on the flexor creases for best testing results.

What Is Included in the Impairment Physical Exam

26 April 2012 / Impairment Physical Exam / 0 Comment

In general, each orthopedic body location is examined in the same sequence order to include the following:

 

Inspection: scars, atrophy, right left asymmetry, deformity, joint contractures, asymmetric gross motion, joint misalignment and muscle fasciculation.

 

Palpation: tenderness, spasm, crepitus, masses, guarding.

 

Range of motion: Use the goiniometer for measurements. “Measurments of active motion take precedence in the Guides. The actual measured goiniometer readings or linear measurements are recorded”. (page 451, Chapter 16, The Upper Extremities, AMA Guides 5th Edition, AMA Press, 2004)Active motion is the motion the employee can do on his/her own.

 

The most common convention is to list right over left side in reporting the measurements, and a minimum of two measurements must be obtained to verify accuracy and reproducibility for rating purposes. The AMA Guides state, "Two measurements made by the same examiner using the Guides that involve an individual or an individual's functions would be consistent if they fall within 10% of each other." (page 20, Chapter 2, Practical Application of the Guides, AMA Guides 5th Edition, AMA Press, 2004).

 

I list the measurement set as “Valid” or “Invalid” based on the 10% reproducibility requirement. This practice helps assists the reader in identifying ratable vs. unratable findings early on in the report.

Spine Examination in an Impairment Rating Exam

24 April 2012 / Impairment Physical Exam / 0 Comment

Doing the exam, I prefer to work from the top of the body down, the same format that is followed in the report dictation. This serves two purposes, it allows the examiner to again have a predictable format to minimize the chance of missed examination data, and, it helps the reader move logically through the findings.

 

Spine Examination

I use a bubble inclinometer for all measurements on the spine regardless of the DRE or Range of Motion Method being used. This is also helpful to insure accurate measurements, and validate asymmetric motion rating on Box 15-1 (page 382, Chapter 15, The Spine, AMA Guides 5th Edition, AMA Press, 2004). Become familiar with bony land marks to use the bubble inclinometer correctly. Use Chapter 15 Spine, AMA Guides 5th Edition, AMA Press, 2004 for full instructional details.

 

Examine both right and left sides on all extremity exams, as this is critical for subtracting the employee’s normal (if any) impairment baseline findings from the injured side when arcs are separated and subtracted in the rating calculations. "If a contra-lateral "normal" joint has less than average mobility, the impairment value(s) corresponding to the uninvolved joint can serve as a baseline and are subtracted from the calculated impairment for the involved joint". (page 453, Chapter 16, The Upper Extremities, AMA Guides 5th Edition, AMA Press, 2004).

Measuring Atrophy in The Impairment Physical Exam

10 April 2012 / Impairment Physical Exam / 0 Comment

“Atrophy is measured with a tape measure at identical levels on both limbs. For reasons of reproducibility, the difference in circumference should be 2 cm or greater in the thigh and 1 cm or greater in the arm, forearm or leg.” (page 382, Box 15-1, Chapter 15, The Spine, AMA Guides 5th Edition, AMA Press, 2004)

 

For neck and upper extremity injuries measure right and left side circumferences for comparison. For the upper extremities measure mid bicep, mid forearm and wrists. If rating specifically elbows, also include the elbow measurements here.

 

Likewise, for lower extremity cases, measure mid thigh, calf and ankle. The thigh is measured 10 cm above the patella, and the calf is measured at the maximum level bilaterally (page 530, Chapter 17, The Lower Extremities, AMA Guides 5th Edition, AMA Press, 2004).If rating the knee, also include the knee measurements.

Eric Schmidt, MD - Director of Orthopedics and Complex Shoulder Program

29 March 2012 / Impairment Rating Specialists / 0 Comment

Dr. Eric Schmidt is our Director of Orthopedics and Complex Shoulder Program.

Dr. Schmidt has been practicing as a pioneer in arthroscopic orthopedic surgical medicine since 1998. He has become a leading advisor and visionary in equipment design, high definition video display and shoulder replacement implants. After completing his undergraduate work at the University of California, Davis with a Bachelor of Science in Physiology, he continued on to medical school also at the University of California, Davis. He moved on to residency at the University of California, San Francisco and then moved to Kaiser in Santa Rosa and has finally settled into private practice.

Dr. Schmidt is an expert in complex shoulder injuries and surgical revisions. His surgical experience has allowed him the opportunity to make great strides in education and technology in arthroscopic procedures. Dr. Schmidt has extensive experience in Workers' Compensation and Medical Legal evaluations. He has served as consultant and lecturer in both technical industry and academic settings. Dr. Eric Schmidt is currently the CEO and Medical Director of NorCal Specialty Surgery Center.

Dr. Schmidt is active in Occupational Orthopedics and enjoys leading the industry in returning employees back to work.

Visit Dr. Schmidt at the Impairment Rating Specialist website to learn more about his practice.

Henry DeGroot, MD - Program Director of Dermatologic Disease and Surgery

27 March 2012 / Impairment Rating Specialists / 0 Comment

Dr. Henry DeGroot is the Program Director of Dermatologic Disease and Surgery for Impairment Rating Specialists.

Dr. DeGroot began practicing Dermatology in 1998, and is a Diplomate of the American Board of Dermatology. He has experience as an Occupational Medicine Dermatology consultant, and currently is the CEO and Medical Director of NorCal Skin Disease and Surgery. He has clinics in Santa Rosa and Ukiah in Northern California.

After high school he served in the United States Marine Corps both in the States and abroad. He finished his military service in Hawaii and stayed there for his initial undergraduate work at the University of Hawaii. Dr. DeGroot received his Medical Degree with Distinction at Indiana University, where he received numerous awards and scholarships. After completing his Residency at UC San Diego, where he also served as Chief Resident, Dr. DeGroot worked at Kaiser Permanente for 10 years before pursuing private practice. Dr. DeGroot has remained active in teaching and holds academic appointments with both UC Davis and UC San Francisco.

Dr. DeGroot has experience in Occupational Dermatology and serves as both as a consultant and secondary treating physician. Visit Dr. DeGroot at the Impairment Rating Specialists website to learn more about his practice.

Why Our Impairment Reports Are So Different

22 March 2012 / Impairment Rating Specialists / 0 Comment

Impairment reports and impairment ratings are critical to the correct and timely closure of a workers’ compensation claim. In California, when the treating doctor needs to summarize the claim, he/she needs to write a PR4 Report to review the essential elements of the claim, and perform an AMA Guides 5th Edition impairment rating, required by law.

 

The impairment rating report is a multi-use document used by doctors, lawyers, judges, insurance companies, and employees. The writing of an impairment report must be exceedingly clear and focused.

 

Our experts help doctors and adjuster improve the quality of reports. We understand the time and expertise that goes into writing a correct summary report (PR4, QME, AME and IME) because we have written and reviewed thousands! Collectively, our associates have over 90 years of medical and legal practice experience. We place high value on accurate and reproducible evaluations. Our report formats are constantly reviewed and updated to insure they meet the highest standards of clarity, organization and opinions that are consistent with the AMA Guides to the evaluation of permanent impairment rating.

 

Why Our Reports Are So Different

We have done the research. We have reviewed thousands of impairment reports and incorporated only the “best of the best” in our report delivery design. We know that an excellent report demonstrates the examiner’s competency in five basic skill sets.

 

1. Subjective History:

The history is the employee’s opportunity to have their story told. Every claim is unique and we bring a high level of personalization to each narrative so the reader can best understand the employee’s recall and decisions he/she made in the course of their care. We tell that story in a strictly non-judgmental voice, including quotations direct whenever possible and written in the “employee’s voice”.

 

2. Chart Review:

Chart reviews are important as they serve as a parallel check to the history provided by the employee. Our review notes are specially coded and summarized in a format that highlights important information in the opinions and impairment calculation that follow. Charts are also voluminous at times. We understand that this poses a threat to losing the reader’s interest while they try to discern what is and what is not relevant.

 

3. Physical Exam:

Our exams are adhere to the highest standards of impairment rating. All orthopedic exams include measurements obtained by goniometer or dual bubble inclinometer, bilateral extremity comparisons, and a set of three trials to confirm that motion is reproduced and validated within 10% variability. Our founder, Dr. John Alchemy, MD, leads the group’s standards and expectations for the exams. Dr. Alchemy is additionally credentialed as a Certified Independent Medical Examiners (CIME) by The American Board of Independent Examiners (ABIME). The ABIME is an international organization which independently certifies examiners for competency in the correct use of the AMA Guides by proctored written examination.

 

4. Certified Impairment Ratings:

Specialized certified impairment rating sets us apart as leaders and what has made us an innovator in the industry. Each and every one of our reports are reviewed by a Certified Independent Medical Examiners (CIME) and verified as correct with the AMA Guides 5th edition prior to the report being signed and served to the requesting party. Our requirement of using CIMEs demonstrates our commitment to excellence and detail.

 

5. Summarized Discussion Review:

We integrate the entire above essential exam elements into an organized discussion review that outlines the internal consistency and conflict of the data. Opinions are considered on objective and reproducible documentation. The discussion summarizes the key findings and presents it in a usable and understandable format based on claim facts.

Alaraz/Guzman II Ratings and AMA Guides

20 March 2012 / Impairment Rating Specialists / 0 Comment

NEWSFLASH:  ALMARAZ/GUZMAN II RATINGS DO NOT PERMIT THE DOCTOR TO IGNORE THE AMA GUIDES.

I take hundreds of doctor depositions under the AMA Guides across California.

And here is one thing I can share with you:  most doctors believe that Almaraz/Guzman II says they can simply ignore the AMA Guides.

THAT IS COMPLETELY INCORRECT.

In Almaraz/Guzman II, the WCAB said there are 4 criteria which must be met for use of Almaraz/Guzman II for a rating:

First, the doctor must do the rating specified by the Guides for the diagnosed condition correctly, following all instructions in the Guides that go with that rating.  (In 90% of the cases, doctors do not do this.)

Second, the physician must then state that the specified rating in the Guides (which he has done correctly) does not adequately describe the Applicant's impairment.

Third, the physician must indicate the case is extraordinary or complex.  (Many do not do this and use Almaraz/Guzman II in every case.  Wrong.)

And fourth, and most important, the doctor must select another rating in the Guides, perform that rating correctly, and follow all instructions in the Guides relating to when and how that rating is to be done.  

(This is the area where doctors simply try to pick and choose parts of a rating they like and ignore the rest.  In Almaraz/Guzman II, the WCAB specifically said that the Guides are an integrated document and that the doctor must follow the instructions relating to the rating.)

So, don't let doctors tell you that they can simply do the rating anyway they want under Almaraz/Guzman II. This is not accurate.  When they ignore provisions of the Guides, file a Motion to Strike the report as not consistent with the AMA Guides and Almaraz/Guzman II.  

Or, better yet, use a doctor who does the rating correctly.  You can find them at Impairment Rating Specialists or through my Doctor Accuracy List which you can get for free by emailing lizkennedy@askphilwalker.com.

Taking a Great Medical Legal History

15 March 2012 / Impairment Physical Exam / 0 Comment

Know your historian.

Before the doctor even begins the exam, he or she needs to assess the validity of the applicant. Is the applicant reliable? How clearly does the applicant recall the injury? Is there adequate understanding? Should and interpreter be present?

These considerations are all too commonly overlooked. I cannot tell you the number of times I have had applicants bring their children as interpreters, sometimes as young as six years old!

If dealing with a head injury and complaints of memory loss, bring in the spouse or adult children to help with the history. Lay ground rules regarding speaking in turn for the overly helpful spouse who want to talk for the applicant. Make it easy on yourself and the applicant.

Set up the history for success, not failure, early on in the process. If the collection of the history is flawed from the beginning, how accurate do you think the conclusions will be?